ATI Medical-Surgical Final questions with answers graded A+ 2024/2025

ATI Medical-Surgical FinalA nurse is caring for a client who is to have his chest tube removed. Which fo the following actions should the nurse take? - Cover the insertion site with a hydrocolloid dressing after removal. - Provide pain medication immediately after removal. - Instruct the client to perform the Valsalva maneuver during removal. - Delegate removal of the chest tube to a licensed practical nurse (LPN). - correct answer Instruct the client to perform the Valsalva maneuver during removal. The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest to prevent air entry into the pleural space. A nurse is caring for a client who begins having a tonic-clonic seizure while sitting in a chair at the bedside. Which of the following actions should the nurse take first? - Provide oxygen. - Place the client in a side-lying position. - Provide privacy. - Lower the client to the floor. - correct answer Lower the client to the floor. The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. Therefore, if a client begins to have a seizure while sitting or standing, the nurse should first lower the client to the floor to protect him from injury. A nurse is teaching a client how to perform a breast self-exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer? - Lumps that are mobile and tender upon palpation prior to a menstrual period - Multiple round masses that are tender and found in both breasts - Bilaterally darkened areolas - A nontender, hard lump that is palpated in one breast - correct answer A nontender, hard lump that is palpated in one breast The nurse should identify that cancerous tumors are typically hard, fixed, irregular in shape, and nontender to palpation. The nurse should instruct the client to notify the provider promptly if she palpates a hard, nontender lump. A nurse is preparing to change the bed linens of a client who has AIDS and is incontinent of stool. Which of the following personal protective equipment (PPE) should the nurse don prior to providing client care? - Gown - Gloves - Mask - Hair cover - Goggles - correct answer - Gown - Gloves A nurse is assessing a client who has a fractured left femur and is in skeletal traction. Which of the following findings should the nurse report to the provider? - Ecchymosis of the thigh - Serous drainage at the pin site - Chest petechiae - Muscle spasms in the left leg - correct answer Chest petechiae The nurse should identify chest petechiae as an indication of fat embolism syndrome. Clients who have fractures of the long bones, such as the femur, are at increased risk for fat emboli. Fat emboli typically occur 12 to 48 hr after the injury when fat droplets from the marrow enter into the systemic circulation and are deposited in the lungs. The nurse should immediately notify the provider because the client could progress into acute respiratory failure.